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J Thorac Cardiovasc Surg 1997;114:552-559
© 1997 Mosby, Inc.
SURGERY FOR CONGENITAL HEART DISEASE |
This technique has several attractive features. First, the pedicled nature of the pericardial flap should allow growth potential, and the authors provide limited data to support this potential advantage. Second, the extracardiac position of the Fontan pathway should preclude the acute creation of pulmonary venous obstruction by an intracardiac Fontan pathway, an important technical consideration in cases of aberrant systemic or pulmonary venous connection or in cases of left atrioventricular valvular stenosis or atresia. The extracardiac position of the Fontan pathway also would be expected to reduce the systemic thromboembolic risk by eliminating intracardiac patch/baffle material, although there are other intracardiac sources for emboli such as atrial appendages and the cardiac end of the original pulmonary artery.
However, it is my impression that there are two potential drawbacks to the extracardiac lateral tunnel technique performed with pedicled pericardium. First, as I understand the technique, the "floor" of the extracardiac lateral tunnel contains the right pulmonary veins. We have now seen three cases in which anterior compression of the right pulmonary veins by a markedly enlarged right atrium has occurred late after a "classic" Fontan procedure in which the atrial septal defect was closed and an atriopulmonary connection was created. Although the authors' technique should avoid creating a massively dilated right atrium, the location of the right pulmonary veins in the floor of the Fontan pathway would appear to put them at risk for compression by the chronically higher pressures within the Fontan pathway. The authors have not reported detailed echocardiographic angiographic follow-up to address this question, nor have they carried out lung scans to determine the relative distribution of blood flow between the right and left lungs. These data will be very important in the longer term evaluation of the technique. Finally, although the authors have reported no difficulties with sinus node dysfunction or arrhythmias, it is my impression that the pericardial flap to the atrial suture line must cross in some proximity to the sinus node; therefore long-term rhythm issues may still be a concern with this technique. Holter monitor data will also be important in the long-term evaluation of this technique.
In summary, Dr. Gundry and colleagues have described an interesting modification to the Fontan technique, which has significant potential advantages but some important potential for late problems. Longer follow-up information will be essential to more complete evaluation of this technique.
John E. Mayer, Jr., MD
Department of Cardiac Surgery
The Children's Hospital
300 Longwood Ave.
Boston, MA 02115
12/6/84441
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